University of KentuckyUKnowledge

DNP Practice Inquiry Projects College of Nursing

2013

The Effect of Coaching on Nurse ManagerLeadership of Unit Based PerformanceImprovement: Exploratory Case StudiesCynthia A. BaxterUniversity of Kentucky College of Nursing, cyndibaxter@windstream.net

This Practice Inquiry Project is brought to you for free and open access by the College of Nursing at UKnowledge. It has been accepted for inclusion inDNP Practice Inquiry Projects by an authorized administrator of UKnowledge. For more information, please contact UKnowledge@lsv.uky.edu.

Recommended CitationBaxter, Cynthia A., "The Effect of Coaching on Nurse Manager Leadership of Unit Based Performance Improvement: ExploratoryCase Studies" (2013). DNP Practice Inquiry Projects. Paper 3.http://uknowledge.uky.edu/dnp_etds/3

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REVIEW, APPROVAL AND ACCEPTANCE

The document mentioned above has been reviewed and accepted by the students advisor, on behalf ofthe advisory committee, and by the Associate Dean for MSN and DNP Studies, on behalf of theprogram; we verify that this is the final, approved version of the students Practice Inquiry Projectincluding all changes required by the advisory committee. The undersigned agree to abide by thestatements above.

Cynthia A. Baxter, Student

Dr. Carolyn Williams, Advisor

i

Final DNP Project Report

The Effect of Coaching on Nurse Manager Leadership of Unit Based Performance

Improvement: Exploratory Case Studies

Cynthia Baxter, DNP, MSN, RN, ACNS-BC, NEA-BC

University of Kentucky

College of Nursing

December 2013

Carolyn Williams, PhD, RN- Committee Chair

Nora Warshawsky, PhD, RN- Committee Member

Karen Hill, DNP, RN- Committee Member Clinical Mentor

ii

Dedication

I dedicate this doctoral capstone project to my husband Marty who has taken on

extra house husband duties for the last three years and my children Justin and Katie.

iii

Acknowledgement

I acknowledge my committee for their support during my progression during my

doctoral study and the wonderful nurse managers who participated in the case studies.

iv

Table of Contents

Acknowledgement....iii

List of Tables..x

List of Figures....xi

Introduction- DNP Capstone Overview..1

Manuscript 1- Exploring the Acquisition of Nurse Manager Competence3

Manuscript 2- Coaching Nurse Managers for Success.25

Manuscript 3- The Effect of Coaching on Nurse Manager Leadership of

Unit Based Performance Improvement: Exploratory Case Studies.......54

Capstone Report Conclusion.90

Appendices...92

Capstone Report References96

v

List of Tables

Sample Distribution by Years of Nurse Manager Experience18

Perceived level of competence using Benners Scale19

Benners Competency Levels of Skill Acquisition44

Research Summary of Coaching Literature Review..45-48

Summary Table of Benefits of Coaching for Individuals and Organizations49

GROW and SMART Models for Goal Development50

Benners Theory of Skill Acquisition...80

Questions to Assess Perceptions of Coaching Experience81

Coaching Model and Lessons Learned.82

Nurse Manager TQManager Scores and Nurse Manager Characteristics...83

Comparison of TQManager Scores with Benners Novice to Expert Scale..84

Comparison of Veterans Administration VATAMMCS Performance Improvement Model, LEAN Performance Improvement Model, Iowa Evidence Based Practice Model and the Blended Model Developed in This Study..85

vi

List of Figures

The Nurse Manager Leadership Partnership Learning Domain Framework20, 51

Self-Assessed Competence for Nurse Managers with < 2 years of Experience..21

Self-Assessed Competence for Nurse Managers with 3-5 years of Experience..22

Self-Assessed Competence for Nurse Managers with 6-9 years of Experience..23

Self-Assessed Competence for Nurse Managers with 10 or more years of Experience...24

Theoretical Constructs of Coaching.52

Comparison of Nurse Manager Pre and Post Coaching TQManager

Self-Assessment with Years of Nurse Manager Experience...86

Nurse Manager B Acute Care Hospital Acquired Pressure Ulcer (HAPU)

Rates Pre, During and Post Coaching87

Nurse Manager C Acute Rehabilitation Long Term Care Hospital Acquired

Pressure Ulcer (HAPU) Rates Pre, During and Post Coaching.88

Nurse Manager A Orthopedic Surgical Suite Turn Over Times.89

1

Introduction to Final DNP Capstone Report

Cynthia Baxter

University of Kentucky

2

The nurse manager role has experienced an explosion of responsibilities and

expectations over the last decade. As a result, competency and skill acquisition for the

successful nurse manager has become the focus of many nurse managers, nurse

executives, researchers and organizations. The three manuscripts contained in this final

capstone report will explore the acquisition of nurse manager competency, propose

coaching as a methodology for acceleration and improvement of nurse manager skill

acquisition and describe the results of three case studies using coaching as an

intervention to improve the performance improvement skill acquisition of nurse

managers.

3

Manuscript 1

Exploring the Acquisition of Nurse Manager Competence

4

Title Page

Title: Exploring the Acquisition of Nurse Manager Competence

Authors:

Cynthia Baxter, RN, MSN, ACNS-BC, NEA-BC

Chief Nurse Medicine Specialty Clinics, Emergency Department, Primary & Telephone

Care

Veterans Administration Medical Center

1101 Veterans Drive, Mail Code 118 CD

Lexington, Kentucky 40502

cynthia.baxter@va.gov

Nora E. Warshawsky, PhD, RN, CNE

Assistant Professor

College of Nursing

University of Kentucky

Lexington, Kentucky 40536-0232

859-323-5815

nwa229@uky.edu

Cynthia Baxter and Nora Warshawsky report no financial interests or potential conflicts

of interest.

This manuscript is written using AMA reference style and is in press for Nurse Leader

publication.

5

Abstract

In the increasingly complex environment of healthcare, the nurse manager

provides vital leadership for healthy work environments, positive patient outcomes and

achievement of organizational goals. However, the development of skills critical for

success is often overlooked and new nurse managers struggle during their role transition

from a clinical provider to nursing leadership. This article presents the results from two

institutions using the Nurse Manager Skills Inventory Tool that accompanies the Nurse

Manager Leadership Partnership Learning Domain Framework to explore the

acquisition of nurse manager competence.

6

Background

In the increasingly complex environment of healthcare, the nurse manager

provides vital leadership for healthy work environments, positive patient outcomes and

achievement of organizational goals. However, the development of skills critical for

success is often overlooked and new nurse managers struggle during their role transition

from a clinical provider to nursing leadership. The Nurse Manager Leadership

Partnership Learning Domain Framework (Learning Domain Framework) was

developed through collaboration between the American Organization of Nurse

Executives and the American Association of Critical Care Nurses.1,2 (Figure 1) The

evidence based framework consists of three domains: the development of the leader

within, the science of managing the business and the art of leading people.3-11

Leadership skills begin with knowing ones self and skills required for success in the

leader within domain include personal mastery of emotional intelligence, accountability

and responsibility for ones communication and actions, developing authentic leadership

skills of self discovery and improvement, and developing enough self confidence to

empower others.11 The science of managing the business spans a collection of skills

that enable the nurse manager to plan strategically for quality care and financial stability

of their area of responsibility. Using foundational thinking, clinical knowledge,

performance improvement methodologies and technology skills, the nurse manager

manages financial and human resources to efficiently improve quality care. To manage

the business, the nurse manager must be able to lead the people by managing

relationships and influencing others toward common goals by fostering teamwork,

developing trust and managing conflict.11 The three competency domains reflect the

explosion of responsibility and expectations of the current nurse manager role.

7

Based on a review of the literature, nurse managers and nursing staff perceive

competencies that revolve around management of the unit at a higher priority than nurse

executives.3,4,6,8 Those competencies include staffing and scheduling, empowering and

development of staff, unit operations, teamwork, communication, and conflict resolution.

Nurse executives ranked competencies focused on organizational strategic planning,

finance and analytical thinking higher than unit based competencies.3,4,6,8 Anthony also

found that nurse managers prioritized competence differently based on their level of

formal education.6 Nurse managers holding an Associate Degree were more focused on

tasks or operations, those with a Bachelors Degree were more focused on professional

development and those with a Masters Degree were more organizationally focused.

Kleinman found differences between nurse managers and nurse executives in the

importance placed on formal educational.4 Nurse executives desired masters level

education for nurse managers much more strongly than did nurse managers. Formal

graduate education promotes broader system thinking skills needed for success in both

current nurse manager and future nurse executive roles.

While the review of the literature emphasized defining the necessary

competencies and skills demonstrated by successful nurse managers and less on the

acquisition and development of these important skills, nurse managers and executives

alike agreed that significant challenges existed for the new nurse manager. Those

challenges were the vast responsibilities of the nurse manager role, the lack of

knowledge and skills of new nurse managers to achieve success, and the constant

competing priorities and demands on the nurse managers time.6-8 These challenges

can be overwhelming and nurse managers have difficulty balancing the responsibilities

of their new role. Much like the journey for new graduate nurses described by Benner,

new nurse managers, or experienced managers with new responsibilities, acquire new

8

skills by following the journey of novice to expert requiring orientation and development

to be successful in their new role.11, 12 The Nurse Manager Skills Inventory Tool

accompanying the Learning Domain Framework is designed to assess the learning

and development needs of nurse managers and is based on Benners Novice to Expert

theory of skill acquisition.1,2,12

Nursing leaders at the Veterans Administration Medical Center (VAMC) and the

University of Kentucky Health Care Enterprise (UKHC) in Lexington, Kentucky wanted to

develop a competency based orientation and development program for their nurse

managers. The Nurse Manager Skills Inventory Tool is designed to assess strengths

and weaknesses and identify areas of development for nurse managers based on the

Learning Domain Framework. Both organizations independently utilized the Nurse

Manager Skills Inventory Tool to perform baseline assessments of their nurse

managers perceived competency. This article will present a comparison of the self

assessed competency of the nurse managers employed by the two organizations and

how the information guided program development.

Methods

A voluntary, electronic survey design was administered to all nurse managers

working at the VAMC and UKHC. Institutional Review Board approval was obtained

from the VAMC and the University of Kentucky. Thirty-seven nurse managers

completed the on line assessments. The distribution by organization and years of

experience are presented in Table 1. The return rate was 89% for VAMC (n=16, N=18)

and 44% for UKHC (n=21, N=48).

The Nurse Manager Skills Inventory Tool was used to assess the 15

competencies in the three domains of the Learning Domain Framework. Nurse

9

managers were asked to rate themselves according to their perceived level of

competence using Benners scale of 1 = Novice, 2 = Advanced Beginner, 3 =

Competent, 4 = Proficient, and 5 = Expert as directed by the Nurse Manager Skills

Inventory Tool.12 (Table 2)

Analysis

At the VAMC, detailed descriptions of the skills included in each competency

category were provided and nurse managers were asked to rate each category. The

category skills were averaged to create mean scores for each competency. At the

UKHC, organizational specific items related to each of the competency categories were

developed and nurse managers were asked to rate each item. Items scores were

averaged by individual and then averaged to create mean scores for each competency

category. The data were analyzed using Statistical Package for the Social Sciences.13

Mean scores for each competency were determined by years of experience and for each

organization.

Results

The domains of managing the business (science) and leading the people (art)

are presented in Figures 2 through 5. The leader within is not represented in the

figures because it was only collected at VAMC. For both organizations, nurse

managers perceived competence increased with years of nurse manager experience

and with the exception of clinical practice, it took 6 years for most competencies to reach

proficient (4) level. It also took 6 years for the science of managing the business to

reach the same perceived level of competence as the art of leading the people. In both

organizations the only competency that nurse managers rated as expert or near

10

expert (5) level was clinical practice once nurse managers achieved 6 to 10 years of

experience.

For nurse managers with less than 2 years of experience, clinical practice (in the

science domain) was the highest perceived competency (VAMC m = 3.67 and UKHC m

= 3.64). The lowest perceived competencies were all within the science domain and

reached below or at advanced beginner scale (2): financial management (VAMC m =

1.33 and UKHC m = 1.67), performance improvement (VAMC m = 1.88 and UKHC m =

2.00), foundational thinking (VAMC m = 2.00 and UKHC m = 1.93) and strategic

management (VAMC m = 2.00 and UKHC m = 1.96). The two other competencies

within the science domain (human resource management and technology) ranged from

just above advanced beginner (2) to barely approaching competent (3). Scores in the

art of managing the people domain (human resource leadership, relationship

management, diversity and shared decision making) were higher than the science

domain with most being perceived at competent (3) or slightly below.

Nurse managers with 3 to 5 years of experience rated themselves only slightly

higher. Again, the range of perceived competency for those skills in the art category

(means of 2.75 to 3.5) ranged higher than those in the science (means of 1.28 to 3)

category. The highest perceived competency was clinical practice (VAMC m = 3.75 and

UKHC m = 2.75), the lowest were financial management (VAMC m = 2.00 and UKHC m

= 1.89), performance improvement (VAMC m = 3.25 and UKHC m = 1.93), technology

(VAMC m = 2.75 and UKHC m = 2.17) and strategic management (VAMC m = 2.75 and

UKHC m = 1.38). Performance improvement showed slightly better perceived

competence when compared with nurse managers with less than 2 years of experience

with a mean range of 1.93 to 3.25.

11

At 6 to 9 years of nurse manager experience, there was notable increase in all

competency categories and again, the highest perceived competency was clinical

practice (VAMC m = 5.00 and UKHC m 4.75). Consistent with the findings of the

perceived competency of nurse managers with less than 2 years and 3 to 5 years

experience, the perceived competency of those with 6 to 9 years of experience was

higher in the art domain (mean scores ranged from 3.35 to 4.41) than in the science

domain (excluding clinical practice) with mean scores ranging from 2.57 to 3.80. The

lowest rated competencies were technology (VAMC m = 3.50 and UKHC m = 2.57),

financial management (VAMC m = 3.00 and UKHC m = 3.19), and strategic

management (VAMC m = 3.00 and UKHC m = 3.33). Although foundational thinking

approached the proficient level (4) with mean scores of 3.50 (VAMC) and 3.80 (UKHC),

none of the science domain competencies (excluding clinical practice) reached proficient

(4) levels.

Nurse managers with 10 or more years of experience again scored their clinical

practice (VAMC m = 4.50 and UKHC m = 5.00) competence highest, reaching expert (5)

or just slightly below expert levels. There was minimal change in the perceived

competence in the art (mean scores ranged from 3.30 to 4.17) and science domains

(excluding clinical practice, means range of 2.50 to 4.05) over the perceived competence

of nurse managers with 3 to 5 years of experience. The lowest rated perceived

competencies in this group were financial management (VAMC m = 2.5 and UKHC m =

3.67) and strategic management (VAMC m = 3.17 and UKHC m = 3.26). The perceived

competence in the art domain ranged from slightly above competent (3) to slightly over

proficient (4) with mean scores ranging from 3.33 to 4.17 with most competencies

approaching the proficient level.

12

Discussion

This data illustrates that while many clinically strong nurses are promoted to

nurse manager roles, clinical expertise does not prepare the new nurse manager for the

wide range of competencies required for success. Competencies identified in the

Learning Domain Framework and the Nurse Manager Skills Inventory Tool may be

beneficial for interview and selection of candidates for nurse manager positions.

It was remarkable that the nurse managers in two different institutions had similar

perceptions of their management competence. The VAMC is a mid-sized referral center

for smaller Veterans Administration facilities with two divisions located approximately 5

miles apart providing services ranging from outpatient to long term care, including

intensive and inpatient care. The operating inpatient bed capacity is less than 200 with a

large outpatient function. UKHC is an enterprise consisting of three acute care locations

and specialty hospitals for cancer, pediatric and cardiac care as well as a large

outpatient service. It is a tertiary medical center for Kentucky and contiguous states with

an operating bed capacity over 700+. The only notable differences in perceived

competence, defined by a difference in means between facilities of 1 or more, were an

increase in perceived competence of strategic management (VAMC m = 2.75, UKHC m

= 1.38) and clinical practice (VAMC m = 3.75, UKHC m = 2.75) at 3 to 5 years.

However, means were equal between the two facilities by 6 to 9 years of experience.

While there were some slight organizational differences, overall the trends

confirmed an increase in competence over time taking approximately 6 years to reach

competent levels for most competencies. Over time, the lowest rated competencies

were finance, performance improvement, foundational thinking and strategic

management. These competencies reflect the broader vision required for succession

13

planning to nurse executive positions from the ranks of nurse managers. Competencies

identified in the literature as those higher in priority for nurse managers and staff, human

resources management and relationship management reached competent and proficient

levels sooner.3,4,6,8 Even so, nurse managers never reached perceived competence of

expert (5) for any competence other than clinical practice and may reflect the dynamic

nature of healthcare and thus, the nurse manager role.

Application to Nurse Manager Development Program Planning

These results support the use of an organized, incremental and integrative

approach to nurse manager orientation and development much like what is already in

place for new nursing graduates following the experiential theory of skill acquisition

described by Benner.12 Typically an interim nurse manager orients the new nurse

manager over a brief period of time and is then available for consultation to the new

nurse manager as issues arise. During the orientation time, both nurse managers are

accountable for the unit but only the new nurse manager is accountable during the

consultation phase. Some organizations have coaching and mentoring programs

designed to support the new nurse manager during the consultation phase or longer.

Some organizations provide classroom education to teach leadership skills for nurse

managers. However, most of these programs are loosely defined and based on current

leadership theories in business and healthcare versus an organized approach specific to

the unique needs of nurse managers.

The Learning Domain Framework provides a model on which to build a nurse

manager specific orientation and development program. The Nurse Manager Skills

Inventory Tool assesses the needs of the nurse manager population and identifies the

starting point to build an organized, incremental and integrated program to accelerate

14

new skill acquisition for both the new nurse manager, and for existing nurse managers

as their roles and responsibilities change. Using Benners theory, nurse managers need

opportunities for experiential learning to build their competency to expert (5) levels.12

Thinking of nurse manager skill acquisition in this manner, pairing up nurse managers

with subject matter experts to complete assignments or projects requiring competencies

identified in the framework and inventory tool might accelerate skill acquisition and lay

the ground work for future success for that competency.

Recommendations for Practice and Future Research

The Nurse Manager Skills Inventory Tool was useful in determining gaps when

planning, implementing and evaluating programs to strengthen nurse manager

competency and to identify the desired qualifications for preceptors and/or coaches for

new nurse managers. The purpose of this article was to report on the findings from two

evidence-based practice projects and not intended to produce generalizable knowledge.

Use of the Nurse Manager Skills Inventory Tool for self assessment by nurse

managers in organizations to guide professional development programs is

recommended. Assessing nurse manager competencies identified in the Learning

Domain Framework and the Nurse Manager Skills Inventory Tool can focus on-going

competency development to broaden the skills of nurse managers to prepare for

advancement to the executive level.3, 7, 8 Cadmus and Johansen recently proposed a

front line nurse manager residency program for new nurse managers with less than 2

years of experience.14 While this type of program may pose financial and other

challenges for organizations, the lack of self assessed competence to the competent (3)

level for nurse managers with less than 2 years of experience exhibited in this study

illustrates the need for this type of out of the box thinking. Academic institutions may

find financial benefit in developing a Masters program or short term certificate program

15

designed to build successful competencies for the nurse manager role that includes a

clinical component designed to accelerate skill development according to Benners

theory and the Learning Domain Framework.12

Most nurse executives have informally observed what is now supported in the

literature: patient care units with competent successful nurse managers have healthier

work environments with positive unit outcomes. Further exploration of the relationship of

nurse manager competence in relation to unit specific nurse and patient outcomes would

strengthen the business case for funding nurse manager development programs by

showing strong return on investment for the organization. Future intervention studies to

test the effects of orientation, continuing education, development and/or nurse manager

coaching programs on nurse manager perceived competency and unit outcomes would

focus strategies for strengthening nurse manager competence and the link to

organizational success. Programs shown to accelerate the competence level of the

nurse manager leader would be beneficial to patients, staff and organizations.

16

References

1. American Association of Critical-Care Nurses. The Nurse Manager Skills Inventory

Tool. Web site: http://www.aacn.org/wd/practice/docs/nurse-manager-inventory-

tool.pdf Accessed: January 5, 2012.

2. American Organization of Nurse Executives. The Nurse Manager Skills Inventory

Tool. Web site: http://www.aone.org/resources/leadership%20tools/partnership.shtml

Accessed: January 5, 2012.

3. Dubnicki, C, Sloan, S. Excellence in nursin management: competency-based selection and development. Journal of Nursing Administration. 1991;21(6): 40-45. 4. Kleinman, C. Leadership roles, competencies and education: how prepared are our nurse managers? Journal of Nursing Administration. 2003;33(9): 451-455. 5. Care, W, Udod, S. Perceptions of first-line nurse managers. What competencies are

need to fulfill this role? Nursing Leadership Forum. 2003;7(3):109-115.

6. Anthony, M, Standing, T, Glick, J, et al. Leadership and nurse retention: the pivotal

role of nurse managers. Journal of Nursing Administration. 2005;35(3):146-155.

7. Sherman, RO, Bishop, M, Egenbeger, T, Karden, R. Development of a leadership competency model. Journal of Nursing Administration. 2007;37(2):85-94. 8. McCallin, A, Franskon, C. The role of the charge nurse manager: a descriptive exploratory study. Journal of Nursing Management. 2010;18(3): 319-325. 9. Kramer, M, McQuire, P, Brewer, B, et al. Nurse manager support, what is it? structures and practices that promote it. Nursing Aministration Quarterly. 2007;31(4):325-340. 10. Hart, M. A delphi study to determine baseline informatics competencies for nurse managers. CIN: Computers, Informatics, Nursing. 2010;28(6):364-370. 11. Benner, P. Excellence and power in clinical nursing practice. Menlo Park, CA:

Addison-Wesley; 1984.

12. Sherman, R, Pross, E. Growing future nurse leaders to build and sustain healthy work environments at the unit level. Online Journal of Nursing. 2010;15(1). 13. Statistical Package for the Social Sciences [computer program]. Chicago, Illinios: International Business Machines.

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14. Cadmus, E, Johansen, M. The time is now: developing a nurse manager residency

program. Nursing Management. 2012;Oct:19-24.

18

Table 1: Sample distribution by years of Nurse Manager Experience

Years of Experience

VA (n=15) UKHC (n=21)

Total (n=36)

0-2 3 8 11 3-5 4 4 8 6-9 3 3 6 10+ 6 6 12

19

Table 2: Perceived level of competence using Benners Scale12

Scale Competence

1 Novice 2 Advanced

Beginner 3 Competent 4 Proficient 5 Expert

20

Figure 1: The Nurse Manager Leadership Partnership Learning Domain Framework,

copyright 2006, by the American Organization of Nurse Executives (AONE). All rights

reserved. 1,2

21

Figure 2: Self-assessed competence for Nurse Managers with < 2 years of experience

(UKHC n=8, VAMC n=3)

1

2

3

4

5

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cia

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Figure 3: Self-assessed competence for Nurse Managers with 3-5 years of experience

(UKHC n=4, VAMC n=4)

1

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Figure 4: Self-assessed competence for Nurse Managers with 6-9 years of experience

(UKHC n=3, VAMC n=3)

1

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5

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24

Figure 5: Self-assessed competence for Nurse Managers with 10 years or more of

experience (UKHC n=6, VAMC n=6)

1

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Manuscript 2

Coaching Nurse Managers for Success

26

Abstract

While formal education and training set the foundation for new leadership roles,

coaching helps the nurse manager gain insight and develop skills that are transferred

into practice. This article will examine the benefit, theoretical constructs and model of

coaching for improving skill acquisition for nurse managers.

27

Background

As the leader closest to direct patient care, the nurse manager plays a pivotal

role in linking the organizations mission, vision and goals to the day to day operations

(Thompson, Purdy & Summers, 2008). Nurse manager competency is vital to promoting

healthy work environments, staff performance and positive patient outcomes (Baston &

Yoder, 2012). Unlike the business sector, healthcare hasnt prioritized leadership

development for the middle management level with the same vigor (Ponte, Gross,

Galante & Glazer, 2006). New nurse managers experience significant role transitions

that cause self-doubt, identity shifts, boundary realignments, and unrealistic

expectations to get it right the first time (Weinstock, 2011, p 211). Kowalski and

Casper (2007) expose the myth that new middle managers of any organization are

comfortable and ready to perform within 100 days; it is more realistic to expect that the

role transition will take up to one year to understand the system, culture and politics.

The expectation that new skills are acquired over time, from novice to expert, and

strengthened by experience is supported by Benners (1984) theory of skill acquisition

for nurses (Table 1). Benners theory is applicable to nurse managers in new roles, new

institutions or with new responsibilities.

Successful nurse manager competencies are defined in the Nurse Manager

Leadership Partnership Learning Domain Framework (Learning Domain Framework,

Figure 1) that was jointly developed by the American Organization of Nurse Executives

and the American Association of Critical Care Nurses (AONE, AACN, 2006). The

evidence based framework consists of three domains: the development of the leader

within, the science of managing the business and the art of leading people. The Nurse

Manager Skills Inventory Tool accompanying the Learning Domain Framework is

designed to assess the learning and development needs of nurse managers and is

28

based on Benners novice to expert theory of skill acquisition (AONE/AACN, 2006;

Sherman & Pross, 2010). Using the Nurse Manager Skills Inventory Tool, Baxter and

Warshawsky (in press) found that even after 10 years of nurse manager experience,

most competencies reached proficient but not expert levels. In addition, most

competencies took 6 years to reach competent levels. While formal education and

training set the foundation for new leadership roles, coaching helps the nurse manager

gain insight and develop skills that is transferred into practice (Dubnicki & Sloan, 1991;

Kramer, Maquire, Schmalenberg, C., et al.., 2007).

Coaching is a formal relationship, much like a partnership, focused on meeting

the learning needs of the coachee to improve performance. Coaching differs from

mentoring; a mentor serves as a trusted counselor in a relationship that is self-selected,

informal and long lasting (Decampli, Kirby & Baldwin, 2010). Coaching is similar to

counseling as both are focused on understanding the deeper meaning of behavior but

coaching differs from counseling because both participants are mutually focused on

goals which may not be the case with counseling alone (Machin, 2010, p 45). During

coaching, mutually developed goals are used to map a path for optimal performance

during a time limited relationship by maximizing strengths, improving weakness and

monitoring progress of the coachee (Weinstock, 2011; Kowalski & Casper, 2007;

Decampli, et al., 2010; Davis, Middaugh & Davis, 2008). In the ever changing landscape

and increasing complexity of healthcare, all nurse managers, new to the role or not,

could benefit from coaching to expose them to new ideas, resources and problem

solving techniques (Decampli, et al., 2010). Coaching can unleash a nurse managers

potential much like a professional athlete uses a coach to maximize performance.

29

Review of the literature

To gain an understanding of the potential of coaching as a strategy for nurse

manager development, a review of the literature was performed using CINAHL,

PyschInfo, Cochrane and Google Scholar search engines using the following search

terms in order to narrow the focus for the application of coaching for Nurse Managers:

coaching and Nurse Managers; coaching and middle managers; coaching and nurse

executives; coaching and nursing and management. Articles were limited to English

only, full text, primary research between 2002-2012 describing outcomes for the use of

coaching as a development strategy for nurse managers or middle managers. Of the

340 articles reviewed, 11 articles were relevant to the inclusion criteria; 6 were specific

to nursing and 5 were specific to a variety of business settings (Table 2). The benefits of

coaching identified in the literature review can be organized into two themes, the benefit

to the individual and the benefit to the organization (Rivers, Pesata, Beasley & Dietrich,

2011; Ciller & Terblance, 2010; Karsten, 2010; Karsten, Baggot, Brown & Cahill, 2010;

Simpson, 2010; Wallis, 2010; Argarwal, Angst & Magni, 2009; Meland & Stern, 2009;

Moen & Skaalvik, 2009; Bowles, Cunninham, De La Rosa & Picano, 2007; McNally &

Lukens, 2006). The benefits are summarized in Table 3 and striated by nursing and

business as well as individual and organizational benefits.

The individual benefits derived from coaching align with the three learning

domains identified in the Learning Domain Framework. Coaching improved self-

awareness and personal mastery (the leader within), improved the ability to lead others

(leading people) and developed a wider view of the business (managing the business)

for the coachee. Consistent with Benners theory of skill acquisition, coaching nurse or

middle managers during new or changing roles strengthened individual competencies.

Moen and Skaalvik (2009) demonstrated a difference between middle managers that

30

were coached and those that were not. Middle managers who were coached

experienced improved self-efficacy (p

31

reported higher employee engagement surveys at one year following coaching for new

nurse managers in comparison to their counterparts who did not receive coaching.

Using coaching in a convenience sample of senior managers in a large Fortune 500

banking company, Wallis (2010) demonstrated a return on investment of 317% as a

result of improved and sustained performance of participants. McNally and Lukens

(2006) calculated that the budget neutral, or breakeven cost for their coaching program

to support nurse managers during role transition would be retention of one nurse

manager. They retained 4 nurse managers who indicated that without coaching, they

would have left the institution resulting in a strong positive return on investment.

Managers and employees are motivated when coaching is used as a

management philosophy to develop employees performance instead of only to resolve

issues (Misiukonis, 2011). While formal education and training set the foundation for

new leadership roles, coaching helps the nurse manager put this training into practice.

The true deliverable of coaching is the insight and competence gained by the coachee

that can be transferred into practice (Ponte, et al.., 2006). Consistent with Benners

(1984) novice to expert theory and the goals of coaching, new nurse managers benefit

from coaching to meet expected competencies for individual and organizational

performance.

Theoretical Frameworks of Coaching

Coaching is theoretically grounded in the realm of developmental psychology and

the domain of interpersonal skills (Locke, 2008). Three relevant theories are

described: Behavioral Control Theory (Gregory, Beck, & Carr, 2011; Bandura, 1997),

Self-Efficacy Theory (Bandura, 1997) and Benners Novice to Expert Theory of Skill

Acquisition for Nursing (Benner, 1984). Coaching borrows from all three of these

32

theories in order to change behavior and gain desired outcomes. The inter-relatedness

of these theories as a construct for coaching is illustrated in Figure 2.

One of the primary purposes of coaching is to help the coachee learn to regulate

their own behavior in order to achieve success in the workplace (Gregory, et al.., 2011).

The methodology of coaching should lead to a deeper understanding of self, improve

critical thinking and promote transformational leadership (Locke, 2008). The coach

needs to be able to ask thought provoking questions and authentically share

observations without generating defensiveness while fostering collaboration and trust

(Kowalski & Casper, 2007; Locke, 2008, p 104). Behavioral Control Theory (Gregory, et

al.., 2011; Bandura, 1997) is the foundation for the two action components of coaching:

goals and feedback. The premise of this theory is a simple feedback control loop. In

order to change an undesired outcome to a desired outcome (goal), the individual is

assisted to see a change in behavior by the coach that may result in achieving the

desired outcome (feedback). As a result of this insight, the individual controls or

changes their behavior in order to close the gap between what is desired (goal) and the

undesired outcome currently occurring (Gregory, et al., 2011; Bandura, 1997). Coaching

provides the feedback portion of the loop by mirroring or reflecting back to the coachee

what is observed, or prompting the coachee to self reflect, in order to understand why

the gap exists. Mirroring is when the coach presents a true picture of the situation to the

coachee and reflecting back is paraphrasing back to the coachee what was said. The

true situation may not be congruent with the perception of what the coachee believes is

occurring. These two techniques will assist the coachee in gaining a full understanding

of why the gap exists and to identify actions and goals to close the gap. Feedback and

questioning that lead the coachee to self-reflecting on the behavior that led to an

undesired outcome will provide more specific and useful information to change behavior

33

and prevent defensive or self-defeating emotions that could hamper success (Gregory,

et al., 2011).

Effective coaching leads to improved self-efficacy, empowerment and ultimately

performance that contribute positively to organizational success (Bastin & Yoder, 2012).

Banduras Self Efficacy Theory (1984) expands the feedback control loop to include a

triad of variables self-efficacy: behavior, internal personal factors and the external

environment. Self-efficacy, or control of behavior, is affected by all of these variables;

changes in one variable will cause a change in the other (Bandura, 1997). Because

humans function in a societal group, choices of action within this triad can be facilitated

by the reflective thought that coaching provides. Bandura emphasizes that the internal

personal factors of self-efficacy and self-esteem affect performance and behavior within

the external environment (in this case the work group). Self-efficacy is how a person

views their ability to carry out an action; self-esteem is a judgment of self-worth. These

internal beliefs can work independently of each other. More than high self-esteem is

required to succeed and persons with high self-efficacy can hold such high standards for

themselves that their self-esteem suffers, or conversely, persons with low standards can

have high self-esteem (Bandura, 1997). Coaching can provide the coachee a safe

venue to balance self-efficacy and self-esteem.

Nurse Manager leadership skill development is a journey following the skill

acquisition model of Benners Novice to Expert Theory (1984). In Benners theory, she

emphasizes that knowing how is different that knowing that. Knowing how is learning a

skill, but experience is required to know that. Knowing that includes the linkage of the

bits and pieces of experience that connects the current situations need to what you

have learned in the past. This perceptual grasp is connoisseurship which allows the

practitioner to see the situation as a whole and provide expert action in a way that might

34

not be consciously apparent to the practitioner (Benner, 1984, p 5). Coaching is a

method to support and facilitate the type of self-reflection and introspection required to

gain self-awareness, critical thinking and form alternatives for future action.

Furthermore, coaching provides a safe environment to gain experience and thus

accelerate movement from novice to expert.

The Model of Coaching

All coaching models have the following stages or steps in common: preplanning

and assessment phase, active coaching phase and a follow up phase (Baston & Yoder,

2012; Ponte, et al., 2006; Kowalski & Casper, 2007; Decampli, et al., 2010; Davis, et al.,

2008; Locke, 2008; Gregory, et al., 2011; Whitmore, 2009). In the preplanning and

assessment phase an initial self-assessment alone or in combination with assessments

from others (ie, 360 degree evaluation) is completed. The Nurse Manager Skills

Inventory Tool has been used to assess competencies specific to nurse managers for

practice development (Baxter & Warshawsky, in press; Decampli, et al., 2010). While an

initial assessment is needed in the preplanning stage and is usually accomplished using

some sort of formal tool, informal assessment occurs throughout the coaching

intervention and is used to guide actions of both the coach and coachee during the

process. The initial meeting occurs within the preplanning assessment phase. During

this meeting the coach and coachee begin to form a relationship and agree on a desired

course.

During the active coaching phase, the coachs role is to use techniques designed

to generate self-feedback and insight from the coachee. This holds the coachee

responsible and accountable for their progress and promotes self-efficacy, self-esteem

and critical thinking. The coach must do this in a manner that is empathetic and

35

nonjudgmental to foster the trust and mutual respect required for success. The primary

skills required of the coach are active listening and effective questioning. Active listening

is exhibited by open body posture, maintaining eye contact and observation of coachee

non verbal behavior. As a result of active listening the coach is able to formulate themes

and perceive relationships in the context of the discussion (Whitmore, 2009; Wesson,

2010). Effective questioning (Kowalski & Casper, 2007; Whitmore, 2009) includes

mirroring (presenting the true situation), reflecting back (paraphrasing what the coachee

has said) and summarizing (reducing the conversation to prevailing themes). Questions

should prompt the coachee to self reflect on the sequence of events that led to a positive

or negative outcome so that the coachee can understand what behaviors lead to that

outcome. Once this understanding is achieved, the coach can support the coachee in

determining what alternative actions or behaviors could be used in the future to achieve

or strengthen the desired outcome. These actions or behaviors lead to goals.

Whitmore (2009) suggests starting with open ended questions to allow the

coachee to lead the conversation to their area of concern. Once a concern is identified,

starting broad and moving to more specific questions, avoiding leading questions and

following the interest of the coachee will lead to the root cause of the concern. These

techniques are designed to allow the coachee to gain their own insight and generate

solutions for the issues that arise. Kowalski and Casper (2007, p 175) suggest a

mnemonic (A, E, I, O, U) for asking questions in this manner:

A=awareness of what has been noticed E=experience of thoughts and feelings associated with whatever happened

I =intention in the situation including the purpose and gain O=ownership of the coachees part in the outcome

U=understanding of the situation and the outcomes by the coachee

36

As a result, issues will be identified around which goals for resolution will need to

be mutually established. Gregory, et al. (2011) suggests developing actions that

progressively lead to accomplishment of a more complicated goal and achieving the

lower rung or easier to achieve actions first. This allows the coachee to develop self-

efficacy and build progress as well as provides a framework for the coachee to follow

after the coaching engagement (ie, break it down to more manageable parts). They also

suggest reminding the coachee that set backs are normal and expected, thus goals may

remain flexible and adjusted along the way. Goals should be alignmed with the

organizations goals in order to be supported. Using a model for goal setting can ensure

that all elements for success have been considered and included. The Whitmore (2009)

method for goal setting uses the GROW and SMART models and should be stated in the

positive (Table 4). These models are designed to assist in defining goals that are clear,

achievable and time bound.

As the coachee gains insight, achieves goals and builds self-efficacy, the

coaching relationship winds down with less frequent sessions. The duration of the

coaching relationship can range from a few months to a year or more depending on the

focus of the coaching engagement. During the follow up and close out phase of the

coaching engagement, the activity shifts to monitoring progress, providing follow up and

defining an end to the engagement. It may also include a report to the coachees

supervisor describing the outcomes of the engagement.

Attributes of the Coach and the Coachee

Attributes of both the coach and coachee, consistent with Banduras Theory of

Self Efficacy (1984) affect success and include internal personal factors of both the

coach and the coachee and the relationship between them. The coach should be

37

approachable, demonstrate caring, support and encouragement, have strong

communication skills, be objective and utilize a balance of active listening and reflective

questioning (Baston & Yoder, 2012; Ponte, et al., 2006; DeCampli, et al., 2010; Locke,

2008). While the coach for a nurse manager would need to be knowledgeable about the

healthcare industry, it was not felt by Ponte, et al. (2006) that the coach has to be a

nurse or a nursing leader. Regardless of whether an internal or external coach is

selected, the ability to discuss critical and politically sensitive topics with a neutral party

while receiving objective feedback is identified as essential (DeCampli, et al., 2010). An

internal coach would know the organization, its culture and politics; the external coach

would be unbiased. Different variables specific to the coach or coachee may drive the

selection of a coach such as culture, sex, age, etc (DeCampli, et al., 2010). The coach

should avoid being too authoritative, unclear, emotional or fail to assess the situation

from the clients perspective (Baston & Yoder, 2012).

The coachee should be motivated and receptive to coaching demonstrated by

accepting responsibility for the sessions, actively participating, ensuring clarity of

feedback, working toward goals and providing follow up during the sessions (Baston &

Yoder, 2012). In comparison to other leaders, Ponte, et al. (2006) report that nursing

leaders are described by coaches as having a broader worldview and approach to their

life and work, passion and caring for people, high collaboration and coordination skills,

are good practice managers, and are more sensitive and courageous. Nursing leaders

were also described as less assertive than business leaders, are poor general managers

and at the most senior level, do not provide enterprise-wide leadership through a

nursing lens but limit themselves to advocating for their discipline or profession and lack

confidence even when successful and accomplished (Ponte, et al., 2006, p 323).

38

Comparisons such as these allow both the coach and coachee to approach the

engagement with a wider vision for their goals and performance.

Implications for Practice and Future Research

While coaching is often used to address problems, it should be more widely used

to develop employees. If the organization values coaching, employees are likely to view

coaching as important (Misiukonis, 2011). The use of coaching is an effective strategy

to support nurse managers in a variety of situations: orientation as a new nurse

manager, support during role transitions and during new initiatives and during changing

responsibilities as well as for ongoing development and succession planning. A formal,

structured coaching program for nurse managers will enhance, facilitate and accelerate

skill acquisition and promote individual and organizational benefits faster than orientation

and education alone. The Nurse Manager Skills Inventory Tool identifies strengths and

weaknesses of the nurse manager. As a result of this assessment, an individually

tailored coaching plan for the nurse manger using subject matter experts to accelerate

and refine skill development can be developed.

Further research into the value of coaching as a strategy to improve nurse

manager competency and the links to individual and organizational benefits would

strengthen the themes found in the literature review. The suggestion that the nurse

manager who has been successfully coached, will in turn be able to successfully coach

staff, warrants further investigation and if proved, would increase the return on

investment of a formal, structured coaching program. Pairing subject matter experts

with nurse managers to facilitate skills that individual nurse managers assess

themselves as less than competent deserves further scrutiny due to the short term

39

nature of such a relationship and the high impact possibilities in terms of low cost and

high benefit.

40

References

American Organization of Nurse Executives. (2006). The Nurse Manager Skills

Inventory Tool. Web site:

http://www.aone.org/resources/leadership%20tools/partnership.shtml , Accessed:

January 5, 2012.

American Association of Critical-Care Nurses. (2006). The Nurse Manager Skills

Inventory Tool. Web site:

http://www.aacn.org/wd/practice/docs/nurse-manager-inventory-tool.pdf ,

Accessed: January 5, 2012.

Agarwal, R., Angst, C. M., & Magni, M. (2009). The performance effects of coaching: a

multilevel analysis using hierarchical linear modeling. The International Journal

of Human Resources Management, 20(10), 2110-2134.

Bandura, A. (1997). Self-Efficacy, the exercise of control. New York, WH Freeman and

Company.

Baston, V. D., & Yoder, L. H. (2012). Managerial coaching: a concept analysis.

Journal of Advanced Nursing, 68(7), 1658-1669.

Baxter, C., & Warshawsky, N. (in press). Exploring the acquisition of nurse manager

competence. Nurse Leader.

Benner, P. (1984). Excellence and power in clinical nursing practice. Menlo Park, CA:

Addison-Wesley.

Bowles, S., Cunninham, C. L., De La Rosa, G. M., & Picano, J. (2007). Coaching

leaders in middle and executive management goals, performance, buy in.

Leadership and Organization Development Journal, 28(5), 388-408.

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Cilliers, F., & Terblanche, L. (2010). The systems psychodynamic leadership coaching

experiences of nursing managers. Journal of Interdisciplinary Health Sciences,

15(1),1-9.

Davis, K., Middaugh, D., & Davis, R. (2008). First down! Keeping your team in the

game with great coaching. MedSurg Nursing, 17(6), 434-436.

DeCampli, P., Kirby, K.K., & Baldwin, C. (2010). Beyond the classroom to coaching,

preparing new nurse managers. Critical Care Nursing Quarterly, 33(2), 132-137.

Gregory, J. B., Beck, J.W., & Carr, A.E. (2011). Goals, feedback, and self-regulation:

Control theory as a natural framework for executive coaching. Consulting

Psychology Journal: Practice and Research, 63(1), 26-38.

Haas, S. A. (1992, June). Coaching: developing key players. Journal of Nursing

Administration, 22(6), 54-58.

Karsten, M. A. (2010). Coaching: an effective leadership intervention. Nursing Clinics

of North America, 45, 39-48.

Karsten, M., Baggot, D., Brown, A., & Cahill, M. (2010). Professional coaching as an

Effective strategy to retaining frontline managers. Journal of Nursing

Administration, 40(3), 40-144.

Kowalski, K., & Casper, C. (2007). The coaching process, an effective tool for

professional development. Nursing Administrative Quarterly, 31(2), 171-179.

Kramer, M., Maquire, P., Schmalenberg, C., Brewer, B., Burke, R., Chmielewsk, L., Cox,

K. ,Waldo, M. (2007). Nurse manager support, what is it? structures and

practices that promote it. Nursing Aministration Quarterly, 31(4), 325-340.

Locke, A. (2008). Developmental coaching: bridge to organizational success. Creative

Nursing, 14(3), 102-110.

Machin, S. (2010). The nature of the internal coaching relationship. International

Journal of Evidence Based Coaching and Mentoring, Special Issue 4, 37-52.

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Medland, J., & Stern, M. (2009). Coaching as a successful strategy for advancing new

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Misiukonis, T. (2011). The conclusions middle managers draw from their beliefs about

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Moen, F., & Skaalvik, E. (2009). The effect from executive coaching on performance

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McNally, K., & Lukens, R. (2006). Leadership development, an external-internal

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Ponte, P. R., Gross, A. H., Galante, A., & Glazer, G. (2006). Using an executive coach

to increase leadership effectivenesss. Journal of Nursing Administration, 36(6),

319-324.

Rivers, R, Pesata, V., Beasley, M., & Dietrich, M. (2011). Transformational leadership:

creating a prosperity-planning coaching model for RN retention. Nurse Leader,

October, 48-51.

Sherman, R., & Pross, E. (2010). Growing future nurse leaders to build and sustain

healthy work environments at the unit level. Online Journal of Nursing,15(1).

Simpson, J. (2010). In what ways does coaching contribute to effective leadership

development? International Journal of Evidence Based Coaching and Mentoring,

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middle managers. Organization Development Journal, 26(3), 63-71.

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Wallis, G. (2010). Does a blended programme of development and coaching, produce

sustainable change? International Journal of Evidence Based Coaching and

Mentoring, Special Issue 4, 105-113.

Weinstock, B. (2011). The hidden challenges in role transitions and how leadership

Coaching can help new leaders find solid ground. Holistic Nursing Practice,

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Wesson, K. J. (2010). Flow in coaching conversation. International Journal of Evidence

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Brealey Publishing.

44

Table 1: Benners Competency Levels of Skill Acquisition (1984)

Competency Level Description

Novice No background understanding of the situation, no experience

Advanced Beginner Demonstrates marginally acceptable performance, can recognize aspects or

pieces of a situation

Competent Perceives situations as a whole and can prioritize appropriate actions

Proficient Perceives the situation as a whole and recognizes expected outcomes and

deviations and makes advanced decisions

Expert No longer relies on analytical thinking and has enough experience to intuitively make

connections and pair with appropriate actions

45

Table 2: Research Summary of Coaching Literature Review

(2002 through 2012, CINAHL, PyschInfo, Cochrane and Google Scholar databases using the following search terms: coaching & nurse managers,

coaching and middle managers, coaching and nurse executives, coaching and nursing and management)

Reference Design/Sample Purpose/Findings

Rivers, R, Pesata, V, Beasley, M & Dietrich, M. (2011) Transformational leadership: creating a prosperity-planning coaching model for RN retention. Nurse Leader, 9(5), 4-51.

Qualitative and quantitative pre test and post test design Convenience sample of 18 nurses & nurse managers of an academic medical center

To determine the effects of a life coach on compassion fatigue and cumulative stress. After 3 face to face meetings and weekly telephone calls with a life coach, the participants felt less vulnerable to stress (p

46

Reference Design/Sample Purpose/Findings

effective leadership development? International Journal of Evidence Based Coaching and Mentoring, special issue 4, 114-

case study 8 senior leaders in a single company with multiple businesses using purposeful sampling

Using a semi structured interview approach, the positive benefits of coaching for individuals and the organization were organized into common themes. Positive benefits for individuals were improved confidence, interpersonal skills, self awareness, work life balance, career planning and decision making. Positive benefits for the organization were improved recruitment, retention of good staff, more flexibility leading to better performance, management of risk and perceived good value for coaching program costs.

Wallis, G. (2010) Does a blended programme of developmental and coaching, produce sustainable change? International Journal of Evidence Based Coaching and Mentoring, special issue 4, 105-13.

Descriptive case study Convenience sample of senior managers of a large Fortune 500 banking company in the United Kingdom

To explore whether a leadership development program that includes coaching generates (p 105) changes in performance, a method to measure that change and if change occurs, does it last Following an educational session and one on one coaching sessions utilizing an external coach, the coaching sessions were found to be more positively received and the participants general perceptions were that they had gained skills leading to a wider stakeholder management, more positive personal development and their affect on leading their team for better performance.

Argarwal, R, Angst, C & Magni, M. (2009) The performance effects of coaching: a multilevel analysis using hierarchical linear modeling. The international journal of human resources management, 20(10), 2110-34.

Post implementation quantitative & qualitative descriptive survey analysis Convenience sample of 328 direct sales force (DSF) staff and 93 district managers (DM, ie middle managers) of a large multinational manufacturing company in the US

To determine the effects of coaching on sales performance and job satisfaction at three months following intensive coaching training There was a strongly positive relationship between job satisfaction and sales performance (p

47

Reference Design/Sample Purpose/Findings

International Journal of Evidence Based Coaching and Mentoring, 7(2), 31-49.

19 executives and 108 middle managers in a fortune 500 company were assigned to experimental and control groups

The executives in the experimental group experienced improved self-efficacy (p

48

Reference Design/Sample Purpose/Findings

Rivers, R, Pesata, V, Beasley, M & Dietrich, M. (2011) Transformational leadership: creating a prosperity-planning coaching model for RN retention. Nurse Leader, 9(5), 4-51.

Qualitative and quantitative pre test and post test design Convenience sample of 18 nurses & nurse managers of an academic medical center

To determine the effects of a life coach on compassion fatigue and cumulative stress. After 3 face to face meetings and weekly telephone calls with a life coach, the participants felt less vulnerable to stress (p

49

Table 3: Summary Table of Benefits of Coaching for Individuals and Organizations

Individual Benefits

Organizational Benefits

Nursing Specific

Improved Job Satisfaction Interpersonal skills System thinking Ability to leverage power within the organization Manage boundaries Relationship with direct reports Self-awareness Work life balance Self-care Decreased Stress Burnout Role anxiety

Improved Employee satisfaction scores Employee engagement scores Patient satisfaction scores Staff nurse retention Nurse manager retention Decreased Staff turnover Nurse manager turnover

Business Specific

Improved Job satisfaction and performance Leadership skills Interpersonal skills Ability to lead team for performance Self-awareness Work life balance Career planning Decision making Self-efficacy Goal setting Autonomy Accountability Decreased Stress

Improved Recruitment and retention of staff and managers Flexibility leading to improved performance Management of risk Stakeholder management (wider management leading to improved performance) Leadership of teams to better performance Job satisfaction Achievement of goals Return on investment for the cost of coaching program

50

Table 4: GROW and SMART Models for Goal Development (Whitmore, 2009)

G=goals- what would you like to talk about, achieve, resolve, decide, solve, accomplish?

R=reality- what is happening now, what is getting in the way, what have you tried so far?

O=options- if you had unlimited resources, what might you do, what else?

W=whats next- of these options, what are your most powerful steps, what will you do,

what is your level of commitment?

S=specific- what specific results would you like to achieve?

M=measurable- how will you know you are getting there, what would ultimate success

look like, if you completed goal is a 10 (scale of 1-10) where are you now, where would

you like to be within ____ time frame?

A=agreed and accepted- what is our level of willingness to work on this goal, what is

your level of commitment?

R=realistic and reaching- to what degree is this goal a stretch for you, how realistic is it

given your current resources?

T=time bound- what time frame are you willing to commit to?

51

Figure 1: The Nurse Manager Leadership Partnership Learning Domain Framework,

copyright 2006, by the American Organization of Nurse Executives (AONE). All rights

reserved (AONE, 2006)

52

Figure 2: Theoretical Constructs of Coaching

Behavioral

Control

Theory

Self-Efficacy

Theory

Benners Theory

of Skill

Acquisition in

Nursing

Coaching

53

Manuscript 3

The Effect of Coaching on Nurse Manager Leadership of Unit Based Performance

Improvement: Exploratory Case Studies

54

Abstract

The focus of this exploratory study involving three cases is to examine the effect

of coaching on the perceived competence of nurse managers leading performance

based improvement teams on their units and on improving unit performance. Coaching

was used as a method to accelerate skill acquisition, rather than the usual approach of

education alone, based on the idea that when nurses move into the role of a Nurse

Manager they begin at the novice level with respect to acquiring new leadership skills.

The study was conducted in a moderate sized Veteran Administration Medical Center in

the Midwest. A model of coaching is described and evaluated. It appears from the

results that coaching improves the perception of competence, is valued by Nurse

Managers and teaches Nurse Managers how to coach staff teams.

55

Background

Nurse Managers have experienced an unprecedented increase in their

responsibilities and overall influence for organizational success as a result of healthcare

reforms (AONE, AACN 2006; Wiley, 2001; Wong & Cummings, 2007). It is widely

recognized that the nurse manager role is undeniable in shaping healthy work

environments and has the most direct impact on the care delivered within healthcare

systems (AONE, AACN, p 2; Wiley, 2001; Wong & Cummings, 2007; Haas, 1992).

However, the development of successful skill acquisition by nurse managers is often

over looked and new nurse managers struggle during their first few years of role

transition from a clinical provider to a leadership role requiring different skill sets. More

realistically, it can take up to one year to be comfortable and competent in a new role

(Kowalski & Casper, 2007). Benners theory of skill acquisition (1984) for new nurses is

applicable to nurse managers new to the leadership role, given new responsibilities or

leading in a different institution. Benners theory (1984) validates that new skill

acquisition moves from novice to expert, is learned over time and strengthened by

experience (Table 1).

The evidenced based framework of the Nurse Manager Leadership Partnership

Learning Domain Framework (Learning Domain Framework) defines the three

domains of successful nurse manager competencies: the development of the leader

within, the science of managing the business and the art of leading people (ANOE,

AACN, 2006). The Nurse Manager Skills Inventory Tool (AONE, AACN, 2006;

Sherman & Pross, 2010) accompanying the Learning Domain Framework is designed

to assess the learning and development needs of nurse managers and is grounded in

Benners novice to expert theory (Baxter & Warshawsky, in press). Using the Nurse

Manager Skills Inventory Tool, Baxter and Warshawsky (in press) found that nurse

56

managers self- rated competency improved over time but most competencies took 6

years to reach competent levels. Even after 10 years of nurse manager experience,

most competencies reached proficient but not expert levels.

Typically, the nurse manager is oriented to their new role or organization

by a peer nurse manager over a limited time frame. This orientation may or may not

include an educational component designed to strengthen supervisory and leadership

skills. Some programs assign a mentor during the period of orientation. A true mentor is

a voluntary, long term trusted counselor or guide who engages in a relationship with the

mentee rather than an assigned pairing (Decampli, Kirby & Baldwin, 2010). A coach is

an experienced leader who assesses, evaluates and works with the coachee to

strengthen skills identified as essential for the job (Decampli, et al., 2010; Davis,

Middaugh, & Davis, 2008). A coach is not often used to develop nurse manager skill

acquisition but is used to develop middle managers in business settings and executives

in the healthcare setting. Use of coaching to strengthen and accelerate skill acquisition

makes sense.

Evidence suggests that the benefits of coaching can be organized into two

themes, the benefit to the individual and the benefit to the organization (Rivers, Pesata,

Beasley & Dietrich, 2011; Ciller & Terblance, 2010; Karsten, 2010; Karsten, Baggot,

Brown & Cahill, 2010; Simpson, 2010; Wallis, 2010; Argarwal, Angst & Magni, 2009;

Meland & Stern, 2009; Moen & Skaalvik, 2009; Bowles, Cunninham, De La Rosa &

Picano, 2007; McNally & Lukens, 2006). As reported in the literature, individual benefits

from coaching align with the three learning domains identified in the Learning Domain

Framework. Consistent with Benners theory of skill acquisition, coaching nurse or

middle managers during new or changing roles strengthened individual competencies.

Individual benefits to nurse or middle managers who were coached included improved

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job satisfaction, interpersonal and leadership skills, self-awareness, autonomy and

accountability. Nurse and middle managers who were coached developed improved

systems thinking and critical decision making, were able to manage boundaries more

effectively resulting in better work life balance and experienced less stress, burnout and

role anxiety. As a result of coaching, nurse and middle managers experienced improved

relationships with direct reports and were more successful in leading teams. Middle

managers who were coached were more likely to successfully use coaching with their

staff (Argarwal, et al., 2009).

Organizational benefits from coaching nurse or middle managers include

improved employee satisfaction and engagement scores, improved patient satisfaction

scores and increased recruitment and retention of staff and managers. Coaching nurse

or middle managers increased manager flexibility leading to improved performance both

individually and with teams, higher achievement of goals, better management of risk and

a positive return on investment for the cost of the coaching program. Coaching provides

the insight and motivation required to improve nurse manager competence that can be

transferred into practice (Misiukonis, 2011; Ponte, Gross, Galante & Glazer, 2006).

While most organizations provide new nurse manager orientation with a peer nurse

manager, and some organizations include traditional classroom training for nurse

managers that includes both coaching and performance improvement, very few have

programs in place to pair the nurse manager with a coach to actively develop leadership

skills (Karsten, et al., 2010; & Decampli, et al., 2010).

Lageson (2004) demonstrated a positive effect of nurse manager

competence on unit outcomes. Nurse manager competence in quality, or performance

improvement, was a significant predictor for positive staff satisfaction (p

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competency for performance improvement did not reach proficient or expert levels even

after 10 years. While there is some evidence that coaching improves individual

competence and has a positive effect on a variety of organizational outcomes, the

literature review revealed no study using coaching as an intervention to improve the skill

acquisition and competency of the nurse manager in improving unit quality and

performance.

Methods

Objectives

The purpose of this exploratory case study was to examine the effectiveness of a

coaching intervention on the performance improvement (quality) competence and skill

acquisition of nurse managers leading a unit based performance improvement team of

staff and to identify the key attributes of coaching in the setting. The objectives of this

feasibility study were to 1. Improve nurse manager perceived competence, 2. Improve

unit level performance and 3. Evaluate the proposed model of coaching.

Study Design

After Institutional Review Board approval, an intervention study using case

methods was used to evaluate the effectiveness of the coaching intervention and its

components. The use of this design considers each case study individually and then

describes common and contrasting themes found among the participants (Yin, 2009).

An encrypted email was sent to recruit four nurse managers who were not in the direct

line authority of the principle investigator. Volunteers were further screened to ensure

inclusion criteria was met prior to informed consent. Five volunteers responded but only

three met all the inclusion criteria. After informed consent, the nurse manager

participants self-rated their performance improvement (quality) competence using the

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TQManager assessment tool prior to the coaching intervention and again after the

coaching intervention. During the coaching intervention, the nurse managers were

responsible for leading their team of staff in a performance improvement (quality) project

on their unit. To determine the effectiveness of the coaching intervention, the pre and

post intervention self-ratings were compared. Data generated by pre-determined open

ended questions designed to determine the key attributes of the coaching intervention

were organized into themes and described. Unit based performance improvement data

was monitored for three months before, three months during and three months after the

coaching intervention.

Setting

This study took place in a moderate sized federal Veterans Administration facility

in the Midwest. Veterans Administration facilities provide a wide range of services to

Veterans including intensive acute care, specialty and primary outpatient care and

preventive and rehabilitation care. Almost all supervisors received training in LEAN

methodology for efficient process improvement but almost all projects were identified by

senior leadership. Shared governance or the consistent use of an evidence based

practice model had not been implemented. Unless nurse managers had prior

experience elsewhere with process improvement, shared governance or evidenced

based practice, these were new skills for them.

Sample

Three nurse manager participants participated in the case study. Inclusion

criteria were nurse managers with less than 10 years of experience, completion of the

facilitys coaching and mentoring education courses, yellow belt LEAN performance

improvement training and the inability to meet or sustain a unit based performance

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measure as defined by the facility or national benchmark expectations. Inability to meet

or sustain was defined as performance measure mean scores worse than expected

benchmarks for at least 2 of the last 4, or 4 of the last 8, of the most recent quarters.

These inclusion criteria were deemed important in order to evaluate the effect of

coaching on nurse manager leadership of unit based performance improvement teams

rather than the usual practice of classroom education only. Nurse managers were

excluded if they were in the line authority of the principle investigator.

Tool

Lageson (2004) measured quality mindedness and focus by using the

TQManager assessment tool (Schmidt & Finnegan, 1993). This tool assesses 5 key

managerial competences related to creating work environments where quality

management can thrive (Lageson, 2006, p 2). The participants self-rate how often each

statement in the tool is true of themselves; 1- almost never, 2- rarely, 3- sometimes, 4-

frequently, and 5- almost never. Scores below 74 indicate significant room for

improvement for quality mindedness, scores 75-99 indicate some competence but

inconsistent quality mindedness and score 100-125 indicates consistent quality

mindedness. Lageson (2004, 2006) reports a Cronbach of 0.97 and a one

dimensional construct validity using the varimax rotation method for the TQManager

assessment tool. Because this tool measures specific competencies for performance

improvement that are broadly defined in the Nurse Manager Skills Inventory Tool, this

tool was used for assessment of quality improvement competencies of the nurse

managers.

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Data Collection and Evaluation

In addition to the pre and post coaching TQManager self-assessment scores,

field notes were made with each coaching interaction and for the final overall evaluation

interview. Aggregate data assessing the unit based process improvement efforts was

gathered from sources already collected within the facility. Final evaluation of the

coaching intervention was conducted using pre-determined questions designed to

determine the key attributes of coaching in this setting. (Table 2). Pattern matching

logic, identifying common and contrasting results among the participants, was used to

formulate descriptive themes that were strikingly similar among the three individual case

studies thus lending validity to the overall results despite such a small sample size (Yin,

2009, p 136).

The Coaching Intervention

The coaching intervention followed the models described in the literature

consisting of three phases: preplanning and assessment phase, active coaching phase

and the final follow up and close out phase (Baston & Yoder, 2012; Ponte, et al., 2006;

Kowalski & Kasper, 2007; DeCampli, et al., 2010; Davis, et al., 2008; Locke, 2008;

Gregory, Beck & Carr, 2011; Whitmore, 2009). The model of coaching used in this study

is summarized in Table 3.

Pre-Planning and Assessment Phase. During the preplanning and

assessment phase, the nurse managers self-rated their performance improvement

(quality) scores using the TQManager assessment tool. The nurse manager and

coach reviewed the nurse managers areas of needs and interests related to their units

unmet performance measures, the organizations performance improvement

methodology (LEAN) and The Iowa Model (Titler, et al., 2001) for evidenced based

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practice. All nurse managers required at least two individual planning meetings along

with two follow up email contacts and one required three of each.

Basic review of the techniques for LEAN performance improvement and

coaching and mentoring were unexpectedly required even though all participants had

completed the required education sessions for both. Once the performance measures

for the study were chosen, the coach conducted the literature search for evidence based

practice for all participants due to the known lack of knowledge and experience with

evidenced based practice methodologies. All of the nurse managers chose measures

they had previously been unsuccessful in improving because they were interested in

finding a methodology that would be successful. There was supervisor and senior

leadership support for these projects due to the inability to meet benchmarks, thus the

nurse managers felt that the use of coaching was important.

The focus of the literature review was to find actions resulting in successful

performance improvements in similar settings, ie improvement of hospital acquired

pressure rates in acute and long term rehabilitation units and improvements in surgical

suite turnaround times. Additional planning and instruction sessions were required in

order to intensively map out the process prior to moving forward to the active coaching

phase when the nurse manager led unit based performance improvement teams. The

process included how many team meetings, timing of meetings, goals and activities for

each meeting, which staff to invite to participate and how to use both the evidence based

literature and the LEAN process methodologies.

All nurse manager participants wanted their staff to follow a similar line of

plannin